Healthcare Provider Details

I. General information

NPI: 1598721680
Provider Name (Legal Business Name): MARY ELLEN CONLEY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 10/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1230 YORK AVE # 163
NEW YORK NY
10065-6307
US

IV. Provider business mailing address

1230 YORK AVE # 163
NEW YORK NY
10065-6307
US

V. Phone/Fax

Practice location:
  • Phone: 212-327-7348
  • Fax: 212-327-7330
Mailing address:
  • Phone: 212-327-7348
  • Fax: 212-327-7330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0201X
TaxonomyPediatric Allergy/Immunology Physician
License Number19351
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code2080I0007X
TaxonomyPediatric Clinical & Laboratory Immunology Physician
License Number276296-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: